Healthcare Provider Details

I. General information

NPI: 1679977458
Provider Name (Legal Business Name): PUMILIA FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 01/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 S MULFORD RD
ROCKFORD IL
61108-4208
US

IV. Provider business mailing address

755 S MULFORD RD
ROCKFORD IL
61108-4208
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-2410
  • Fax: 815-398-2620
Mailing address:
  • Phone: 815-398-2410
  • Fax: 815-398-2620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number319.010939
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number019021788
License Number StateIL

VIII. Authorized Official

Name: PACITA MARIE PUMILIA
Title or Position: DENTIST
Credential: DDS, DIPLOMATE ABDSM
Phone: 815-398-2410